precautions - ruptured post cruciate ligament

[Fyzzio]

Hi,
I am a neuro Physio and need some musculo advice please:
Have got a young client with severe traumataic brain injury. Last year, he fell down the stairs and sustained a knee dislocation with ant + post cruciate and lat collateral ligament ruptures and also ruptured popl. artery and damaged popl. veins. He underwent a reconstruction for all, but the post cruciate ligament (due to closeness to vascular repairs).
The knee is working fine now and strength is 4/5 mod Ashw., he walks unaided indoors and uses a crutch outdoors for longer distances (mainly due to his severe ataxia).
My question: What are precautions for clients, who function without an intact post cruciate ligament.
I am aware, that he shouldn't do full squats, but what else?
Any comments greatly appreciated,
thanks,
Fyzzio

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[phunphysio]

Hello,


I did a very similar injury 12 months ago, ruptured ACL, PCL and MCL in a trampolining incident...
Had the ACL repaired and MCL stapled and cartilage removed.
PCL couldnt be repaired for same reason.

I did try a few searches at the time to see what I could and couldnt do but difficult to find much.

I find I loose control when the knee is weightbaring and flexed more than 90 deg (like the squat you mentioned). I can feel the shearing in this position so even things like going down a steep step etc has taken me over a year to achieve. Other than that I was told (apart from contact sports) I shouldnt be restricted from doing anything. I also feel shearing when changing direction. PCL limits tibial rotation also, I find I still feel a clunk when changing direction quickly or without thought.

Hope this helps

Phunphysio

[Fyzzio]

Thanks mate,
... that's a good start!!! The guy is alright on normal stairs, but so far, I have told him not to squat on steeper ones and use affected foot first going down big obstacles. So, will stick to that.
Trampolining ... nice one, that must have looked really ugly, too.
Good luck and thanks again,
Fyzzio

[neuromuscular]

What is the condition of the popliteus and planterius? Are they binding the knee, so that he cannot completely extend it?

Hope you find this helpful.

Best regards,
Neuromuscular

[Fyzzio]

Hi,
as I said before, the knee is fine, full range of extension and power 4/5. Although latter is a bit difficult to establish as he suffers from major ataxia.
Wouldn't in his case an overlock of popliteus and planterius be ideal to prevent femur slippng of tibia??????
Enlighten a neuro physio please,
thanks,
Fyzzio

[neuromuscular]

Probably, but it could have a binding and sudden release factor that may appear as an instability.

I do not know as I have not seen him.

The turning of the tibialis on the femur can cause binding of the joint that appears as an instability. If the joint is simply lax due to meniscus problems then this will not be the case.

If the meniscus is damaged, then what about a brace?

Hope that this is helpful.

Best regards,

Neuromuscualr.

[Fyzzio]

Hi,
I have only got the rehab discharge report with a summary of the surgeons report. Menisci weren't mentioned, therefore I presume they were undamaged (..?..).
He's got a brace (Don Joy, full ROM ext, limiting >100 degree flex), which he now only wears for longer distance walking.

But generally, his knee is fine and his surgeon is very happy with the current condition. I really only wanted to know, whether there is anything, he shouldn't do with an unfunctional post cruciate ligament.

Thanks for your help, it made me review the anatomy in more detail,
cheers,
Fyzzio

[neuromuscular]

If there is no cause of the problem other than the torn PCl, you may consider how the hip is impacting on the knee as Hoppenfeld and others infer.

You might see if there is a hip imbalance by landmarking the ASIS to ASIS and having the patient do hip abduction directly lateral in the coronal plane and note if there is a superior or inferior movement of either or both of the ASIS

Then do an ASIS to PSIS on each side with the patient doing a hip abduciton directly lateral in the coronal plane. If either or both are moving into anterior or posterior rotation, the hip may be affecting the knee by extra pressure to it. That is my area of research.

I find that many patients with a knee problem are having an effect on the knee from the hip

For more ideas on the PCL you might contact a sports injury practitioner.

Hope this is of help.

Best regards,

Neuromuscular.

[Fyzzio]

I find that many patients with a knee problem are having an effect on the knee from the hip

I might have not stated it clearly: my client DOES NOT have a knee problem.

And I am aware of your research project, as you comment on it in nearly every post.

But you are completely right, I will contact a sports injury Physio to ask for precautions or don'ts in regards to an unfunctional PCL.


Thanks for all. Cheers,
Andrea

[Hunter_PT]

hahaha...thank god someone told neuromuscular to shut up about his damned research project! NO....ONE....CARES!

[Fyzzio]

Hunter,
maybe you should think twice before you post replies ....
You are misinterpreting what I wrote, your comments are rude and your attitude is appalling.
Regrads,
Fyzzio

[msk101]

HI Fyzzio,

As far as precautions go for a PCL deficient knee they are similar to ACL. Avoid sharp or steep declines that require maximal eccentric quads loading and exert a shearing force on the knee, also a full squat is not ideal as you've already covered. I would also not recommend high velocity kicking (eg a ball or karate style) although it doesn't sound like something your client would be doing. The other thing to watch for is open chain full knee extension due to the shearing forces as well, similarly with high loading hamstring curls from a full knee extension position ... make sure the quads are active as well... start from a 10degree flexed position if you're going to do this as an exercise, however i'd suggest there are more functional closed chain exercises that would be better for you client.

People can quite happily live without a PCL but i would emphasise quads and hamstring co-contraction coordination and strength to increase muscular stability of the knee. I wouldn't encourage the patient to full lock weightbear on the knee because without a PCL that will exert considerably more force on the ACL and isn't ideal when it comes to unlocking.... locking a PCL deficient knee is actually more like hyper extension locking which i would avoid. Avoid pivoting or twisting on that leg as well. Go for muscular strength and cocontraction with quads and hams.

Hope that helps.

Cheers
Msk101

[Fyzzio]

Thanks, mate,
that was great advise!!!
Cheers,
Fyzzio

[neuromuscular]

I might have not stated it clearly: my client DOES NOT have a knee problem.

And I am aware of your research project, as you comment on it in nearly every post.

But you are completely right, I will contact a sports injury Physio to ask for precautions or don'ts in regards to an unfunctional PCL.


Thanks for all. Cheers,
Andrea

Dear fysio:

MSK101 makes some very good points. The joint is mechanical and your expertise is in nerurological. The mechanical aspects are compromised with the PCL restraint gone. The mechanical pressure and vectors of force will be to hyperextend the joint.

You might add to the obvious that your client will have muscle loading and recruitment problems in that the muscles will try to splint or brace the joint. You might consider not just strengthening exercises, but also keeping the proper tonus and balance in the muscles over the joint.

My reference to the hip is that knee problems, ie lack of support, create changes in gait that work themselves through the body in less obvious ways. ( see Hoppenfeld and others.) My reference to the hip assessment is that this should not be overlooked.

Sorry about the negative remarks about my research, but the research has gone beyond me as the OGI, or Ola Grimsby Institute is preparing a research paper on it. I am out of the picture on this as the research is being finished in the USA by another person. The relevance of it to your problem is that it will show if your client is having gait and postural adaptions to his weakened stuctural problem.

Hope this is helpful.

My best to you,

Neuromuscular.